A school-aged child is admitted to the hospital with a vaso-occlusive sickle cell crisis. Which measure in the child's care plan should be given priority?

Encouraging the child to take deep breaths hourly

Maintaining fluids through an intravenous line

Beginning active range-of-motion exercises

Seeing that the child ingests a protein-rich diet

Answer and Explanation

The Correct Answer is B

A. Encouraging deep breathing is important for preventing pulmonary complications but is not the priority in managing a vaso-occlusive crisis.

B. Maintaining hydration through intravenous fluids is the priority as it helps to reduce blood viscosity and prevent further sickling of cells, which is critical in managing a vaso-occlusive crisis.

C. Active range-of-motion exercises are important but are not a priority during an acute vaso-occlusive crisis.

D. A protein-rich diet supports overall health but is not immediately relevant to the acute management of a vaso-occlusive crisis.

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Correct Answer is B

Explanation

Assessing the erythematous rash is important, as it can indicate the presence of erythema marginatum, a common symptom of rheumatic fever, but it is not the priority.

B. Auscultating the rate and characteristics of the child's heart sounds is the priority assessment because acute rheumatic fever can cause carditis, which affects the heart valves and can lead to serious complications. Early detection of any cardiac involvement is crucial for timely intervention and management.

C. Assessing joint pain is necessary for comfort and symptom management but does not take precedence over potential cardiac complications.

D. Identifying parental anxiety is important for providing emotional support but is not the immediate priority in managing the child's acute condition.

A. The toddler cannot build a tower of six to seven cubes. B. The toddler cannot jump with both feet. C. The toddler cannot stand upright without support. D. The toddler cannot turn a doorknob.

Correct Answer is C

Explanation

A. By 15 months, a toddler typically can build a tower of two to three cubes; a tower of six to seven cubes is expected closer to 24 months.

B. Jumping with both feet is generally expected closer to age 2-3 years.

C. By 15 months, a toddler should be able to stand upright without support. Failure to do so could indicate a delay in motor development.

D. Turning a doorknob is a skill that develops later, around age 2-3 years.

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A school-aged child is admitted to the hospital with a vaso-occlusive sickle cell crisis. Which measure in the child's care plan should be given priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an 8-year-old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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